Artificial Hydration at End of Life

Artificial Hydration at End of Life - #77

Key points when discussing risks and benefits of artificial hydration in advanced dementia patients and in patients nearing the end of life:

Observational studies found that patients with abdominal malignancies who received AH at the end of life experienced more peripheral edema, pleural effusions, and ascites (4). Limiting or decreasing the volume of fluid to avoid these adverse outcomes may reduce discomfort.

No difference was found in the prevalence of agitation or delirium between hydrated and not hydrated groups (4).

Family members may perceive their loved ones to be suffering at the end of life due to hunger or thirst. Providing AH may provide these families with emotional and psychological benefit (5, 6).

In chronic illnesses such as advanced dementia, AH will not change the overall trajectory of the disease and may only provide minimal symptom relief.

Proper oral care, artificial saliva, and careful providing of oral fluid as tolerated should be provided, as these interventions may improve symptoms of thirst and discomfort.

A randomized controlled trial (N=129) of cancer patients nearing the end of life received 1000 mL normal saline over seven days vs 100 mL normal saline. Survival was 21 days versus 15 days respectively (p = 0.83) (7). Although not statistically significant, at the end of life artificial hydration may add an additional six-days of survival time. While artificial hydration does not change the course of disease the family and patient need to determine if this is in line with the patient’s care and life goals.

Dementia is characterized by a progressive, irreversible, and expected cognitive and physical decline. The leading causes of mortality in advanced dementia patients are infection and dysphagia (1). Generally, dysphagia increases slowly over time, however, there may be periods where fluid intake abruptly decreases or stops completely. The onset of abruptly decreased oral intake should cue providers and family to search for reversible causes such as painful swallowing, depression, acute medical illness or delirium. However, in many cases no reversible causes are identified. Family members may inquire about the possibility of artificial hydration. Artificial hydration (AH) is defined as providing liquids through non-oral routes, such as intravenous (IV), subcutaneous (SQ), or enteral or parental nutrition (2, 3). Open discussions with family members and patients regarding the risks and benefits of AH when nearing end of life are essential to patient care.